IC7 Nutritional Support Flashcards
What is ileum resection associated with? How can it be managed?
B12 deficiency
It is the site of B12 absorption
B12 supplementation
Which is the most absorptive part of the intestines?
Jejunum
What is the gall bladder’s function and how will diet be affected if it is removed?
Production of bile for fat digestion
Patient may need to be on long-term low-fat meals
What THREE functions do the stomach play?
Acts as an elastic reservoir
Releases intrinsic factor for B12 absorption
Secretes fluids
What syndrome is associated with removal of the stomach?
Dumping syndrome - food passes straight into the small intestine causing abdominal cramps, nausea and diarrhea
Explain how the lack of food in relation to CCK production can cause physiologic complications
CCK is released in the duodenum in response to food passage
it stimulates pancreatic contractions, bile production (liver) and bile release (gall bladder)
without food, CCK is not produced
gall bladder contraction is impaired, affecting biliary flow and causing cholestasis and jaundice
What are the 4 contributing factors to malnutrition?
- (1) Decreased intake and (2) Decreased absorption
- (3) Increased expenditure and (4) Increased losses
What are two instances that can result in (1) decreased intake?
chemotherapy causing nausea, vomiting and taste alterations which can reduce oral intake
abdominal cancers may cause ascites that exerts pressure on the GI tract, causing early satiety and reducing intake
What usually results in (2) decreased absorption?
After major surgery, resecting too much of the intestines will result in malabsorption
What usually results in (3) increased expenditure?
severe stress will increase the body’s energy consumption (e.g. surgery, trauma, sepsis, burns) to promote wound healing and help the body fight off pathogens
What usually results in (4) increased losses?
renal patients on dialysis (protein losses through dialysis machine)
What does malnutrition in healthcare result in? (cp, 4inc)
poor wound healing
compromised immune status
increased complications
impairment of organ functions (due to lack of energy)
increased mortality (more susceptible to underlying conditions)
increased use of healthcare resources
What are the 4 steps of nutritional screening and assessment?
- nutritional screening
- refer to dietician or nutritional specialist
- nutritional assessment (ABCD)
- formulation of nutritional regime
What does ABCD in nutritional assessment refer to?
A - anthropometric data (height and weight)
B - biochemical data (electrolytes and serum albumin)
C - clinical data (PMH, med hx, physical exam, edema)
D - dietary hx
How is serum albumin used as a marker for malnutrition and why is it not the most reliable?
Malnourishment (lack of protein) will cause the body to produce less albumin
Levels are also affected by inflammation and fluid overload
The 3-minNS scoring system is a malnourishment risk assessment framework validated in Asian populations.
What does the 3-minNS scoring consider? (4)
weight loss
how the nutritional intake has been
muscle from the temple
how obvious the clavicle bone is
Nutritional assessment can be assessed using Seven-point subjective global assessment (SGA) which incorporates data from ABCD. What does it consider? (6)
weight loss
dietary intake
symptoms like nausea vomiting and diarrhea
metabolic states that affect the body’s energy demands
muscle and fat wastage
edema
What does the SGA assessment tell us about the patient? What does a scoring of 1 and 7 mean?
gives us an idea of the patient’s baseline nutritional status, how urgent it is to start nutrition for the patient
1 indicates severe malnourishment
7 indicates a well nourished patient
What are the 3 main ways to calculate energy requirements?
- indirect calorimetry
- weight-based calculations
- predictive equations
How does indirect calorimetry work?
measures gas exchanged during consumption of substrates to produce required energy
What formula do weight-based calculations follow?
25-35 kcal/kg for general hospitalised patients
What else needs to be accounted for in weight-based calculations?
age
physical activity
stress factor
What do predictive equations measure and what else needs to be accounted for?
basal metabolic rate
adjust for physical activity and stress factor (age already taken into account in calculations)
How much protein do normal healthy adults require, as well as other non-CKD patients?
Normal healthy adults: 0.8 g/kg/day
Pt w trauma/surgery/burns: 1.5 to 2 g/kg/day
Pt w sepsis/critical illness: 1.5 to 2 g/kg/day or consider up to 2.5 g/kg/day
For CKD patients, how much proteins do
- patients not on dialysis,
- patients on HD/PD
- patients on CRRT
require?
not on dialysis: 0.6-0.8 g/kg/day
HD/PD: 1.2 g/kg/day
CRRT: up to 2g/kg/day
Which patient groups are EN feeds usually given to? (4)
patients who are unable to receive or tolerate adequate nutrition orally
swallowing impairment (usually post-stroke)
altered mental status (reinjury, lose consciousness)
motility disorders (DM patients with gastroparesis)
those on mechanical ventilation
Describe the properties of pre-pyloric feeding and their benefits. (4)
- more physiologic (uses GIT and maintains function)
- higher tolerance for bolus feeding
- higher tolerance for wider range of feeds (esp high osmolarity)
- can be used for venting excess fluids (lowers risk of aspiration pneumonia)
In which patient group should pre-pyloric feeding be avoided in?
patients with delayed gastric emptying
Describe the properties of post-pyloric feeding and their benefits. (3)
- smaller bore so less discomfort
- may be used in conditions that result in proximal GIT dysfunction
- lower aspiration risk
What are the downsides of post-pyloric feeding? (2)
- lower tolerance to high osmolarity enteral products as they draw water out of the intestinal lumen and cause diarrhea
- high risk of tube clogging due to smaller bore
What is the main benefit and downside benefit of nasal tubes?
can be administered at bedside
but
not very comfortable and aesthetically pleasing
What is the main benefit and downside benefit of stomy tubes?
easier to cover up, better for life-long requirement
but
requires surgical procedure that may not heal